11 March 2014
“Sugar daddies destroy lives” say billboard adverts in Kwazulu-Natal in big bold black and red letters. The same message is echoed in radio adverts played across the country.
Supported by the Minister of Health, public health messages are trying to stigmatise relationships between younger women and older men because of the view that these relationships are driving the country’s high number of HIV infections.
But the anti “sugar-daddy” campaign was started with no compelling evidence to support its assumptions.
HIV peaks in women at a much lower age than in men. The thinking behind the campaign was that women are therefore mainly getting infected because they have sex with older men. Now a study presented by a leading research group called the Africa Centre has found that this is not the case. Besides being a waste of HIV prevention money, it might even put some women at more risk of infection.
The findings were presented at the main annual HIV science conference in Boston last week. Guy Harling from the Africa Centre presented the study, which ran from 2005 to 2012 in KZN. His team recruited over 4,000 HIV-negative women and regularly essentially asked them how old the person who they last had sex with was. Over 570 women became HIV-positive during the course of the study.
The researchers compared the age difference of sex partners in the women that remained HIV negative to those that became HIV positive. In women aged 15 to 29, they found that the age gap made no difference to the likelihood of becoming infected. In women older than 30 the wider the age difference the less likely they were to become infected.
While the study did show that most women had older sexual partners, it could not find any evidence this was riskier than having sex with younger men or with men of the same age.
Harling described the anti-“sugar-daddy” campaign as inefficient. He said that if the public health campaign is shifting women over 30 from older partners to younger ones, it is potentially increasing their risk of HIV infection.
The study is not without problems. For one thing, it depends on people answering the questions accurately. People often don’t tell the truth in surveys; more so in a study like this which asks deeply private questions. Also, not all women responded to the questions, which might bias the results, but the response-rate was quite good considering the sexual nature of the questions. The researchers have not yet published the study’s details, which will allow us to assess how good it is.
Nevertheless, it is currently the only large study that looks at age differences between sexual partners and HIV infection. Harling suggested that women select older men more carefully than they select younger men and this might compensate the risk. It is also possible that older men are more respectful and less abusive than younger men. But this is no more than speculation. The truth is we don’t know what puts women in Southern Africa at so much higher risk of HIV than other parts of the world.
The study shows how important it is that public health messaging be based on scientific findings and not on what seems to be common sense. The Treatment Action Campaign (TAC) has promoted many public health messages over the last 15 years. I can think of two examples, when I was involved in TAC, which got it wrong and illustrate the pitfalls that need to be avoided. Most of TAC’s messages were accurate and informative so these should not be seen as typical of the organisation. I use these examples because of my first-hand experience with them and also because the mistakes we made are instructive.
Over a decade ago, TAC pushed for wider availability of a medicine called acyclovir to treat herpes. Our poster said, “Untreated herpes helps spread HIV.” Treating herpes is a good thing to do, but the claim that treating it helped reduce the spread of HIV, while commonly believed at the time, was free of evidence. Clinical trials later showed that acyclovir did not help reduce HIV infections. This is an example of a public health message that turned out to be factually wrong.
A second public message TAC promoted was, “Use a condom every time you have sex” with the purpose of preventing HIV infection. It is true that using a condom every time you have sex will make it very unlikely for you to contract (or transmit) HIV. But it’s impractical advice. What about couples in long-term relationships, or trying to get pregnant? What about the fact that many people find it really hard, for various reasons, to use a condom every single time they have sex?
While the message was factually correct, it was also telling people how to behave. This is an example of a public health message that is moralising. Public health messages should inform, not moralise. “Using a condom can prevent you from becoming HIV-positive” is an informative message. “Use a condom” is a moralising one.
The anti-”sugar-daddy” message has both these pitfalls. The evidence doesn’t support it, and the message is moralising because it blames a class of people, older men who have sex with younger women, for the HIV epidemic. It tells people how to behave. No doubt this is a popular idea: many people think it is yucky for men to have sex with women much younger than them, but yuckiness should not be a consideration for public health messages. It is an arrogant message because it presumes that when government or NGOs tell people how to behave they listen. It also implies that all relationships with large age differences are the same: young women who want material benefits having sex with older lecherous men. What an absurd thing to believe when human experience is so diverse and the reasons for age gaps in relationships must be multitudinous.
One of my colleagues felt that the anti-“sugar-daddy” campaign’s subtext is that women are victims, incapable of making autonomous decisions about sex. Another said it seems to be informed by racist ideas about African men’s sexuality. These are harsh judgments of the campaign’s motives, but not implausible ones.
Professor Francois Venter treats a large number of HIV-positive patients in Johannesburg. He has been an outspoken critic of HIV behavioural change programmes. He says, “It increasingly seems that sexual messaging is based on fuzzy-minded morality, rather than evidence. We need to stop advocating ‘common-sense’ HIV prevention. What alarms me is that the HIV prevention field has not just wasted money, but may have created stigma and increased HIV transmission risk, by advocating this.”
Neither the state nor NGOs should presume to tell people how to behave when it comes to their health. Public health messages should rather stick to providing accurate information based on scientific evidence so that people can make informed choices.